Management of stage D1 adenocarcinoma of the prostate: the Johns Hopkins experience 1974 to 1987

Cytoreductive prostatectomy may improve oncological outcomes in patients with oligometastatic prostate cancer: An updated systematic review and meta-analysis

The oncologic outcomes of cytoreductive prostatectomy (CRP) in oligometastatic prostate cancer (OmPCa) are still controversial. Therefore, we conducted a systematic review and meta-analysis on the oncologic outcome of CRP in OmPCa. OVID-Medline, OVID-Embase, and Cochrane Library databases were searched to identify eligible studies published before January 2023. A total of 11 studies (929 patients), 1 randomized controlled trial (RCT) and 10 non-RCT studies, were included in the final analysis. RCT and non-RCT were further analyzed separately. End points were progression-free-survival (PFS), time to castration-resistant prostate cancer (CRPCa), cancer-specific-survival (CSS) and overall-survival (OS). It was analyzed using hazard ratio (HR) and 95% confidence intervals (CIs). In PFS, in RCT, HR=0.43 (CIs=0.27-0.69) was shown statistically significant, but in non-RCTs, HR=0.50 (CIs=0.20-1.25), there was no statistical difference. And, in time to CRPCa was statistically significant in the CRP group in all analyses (RCT; HR=0.44; CIs=0.29-0.67) (non-RCTs; HR=0.64; CIs=0.47-0.88). Next, CSS was not statistically different between the two groups (HR=0.63; CIs=0.37-1.05). Finally, OS showed better results in the CRP group in all analyses (RCT; HR=0.44; CIs=0.26-0.76) (non-RCTs; HR=0.59; CIs=0.37-0.93). Patients who received CRP in OmPCa showed better oncologic outcomes compared to controls. Notably, time to CRPC and OS showed significantly improved compared with control. We recommend that experienced urologists who are capable of managing complications consider CRP as a strategy to achieve good oncological outcomes in OmPCa. However, since most of the included studies are non-RCT studies, caution should be exercised in interpreting the results.

Treatment of the primary tumor in metastatic prostate cancer

The cornerstone of treatment for metastatic prostate cancer patients has been conventional androgen deprivation therapy, with additional systemic therapy initiated only after castration resistance, and local therapy reserved for palliation. Compelling results from modern trials challenge this paradigm, arguing for initiating escalated hormone therapy and/or chemotherapy during the castration-sensitive disease state for many patients. Furthermore, modern radiotherapy techniques allow for local control of disease with low risk of toxicity. Finally, new PET probes with enhanced sensitivity and accuracy are likely to become a part of routine staging and will lead to an increased incidence of patients with metastatic disease at presentation, with a shift toward identification of patients with limited metastatic disease. As such, the landscape is primed for investigations aimed to explore the role of primary tumor therapy for patients with metastatic prostate cancer. We review the existing data evaluating primary tumor therapy for patients with metastatic prostate cancer and describe ongoing clinical trials testing the hypothesis that primary tumor therapy may benefit patients with metastatic prostate cancer.

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.

Cytoreductive prostatectomy in metastatic prostate cancer: a systematic review

The impact of cytoreductive radical prostatectomy on oncological outcome in patients with prostate cancer and limited number of bone metastases is unclear. Data from cancer registries, multi-institutional databases and a single institutional case-control study indicate a possible benefit of combined cytoreduction and hormonal therapy compared to hormonal therapy alone. However, the results may be biased by a number of factors. The evidence from studies on cytoreductive prostatectomy is reviewed.

Cytoreductive radical prostatectomy in metastatic prostate cancer: Does it really make sense?

PURPOSE

Surgical removal of the primary tumor in metastatic prostate cancer (mPCa) is becoming a hotly debated issue. The purpose of this review was to summarize the current knowledge on cytoreductive radical prostatectomy (cRP) in this setting.

MATERIALS AND METHODS

We performed a non-systematic Medline/PubMed literature search of articles published in the field between January 2000 and April 2015.

RESULTS

Cytoreductive surgery has demonstrated its benefit in various malignancies with a solid biological rationale to justify its assessment in mPCa. cRP appears as a safe and feasible procedure in expert hands and well-selected patients. A growing body of evidence suggests a survival benefit for patients undergoing cRP as a part of a multimodal approach compared to those treated with systemic treatment alone. Nevertheless, little is known about the best clinical and tumor characteristics for the selection of patients most likely to benefit from cRP. The current literature is based on retrospective studies with small cohorts and limited follow-up or large uncontrolled population-based studies.

CONCLUSIONS

Data from various other malignancies together with the biological rationale and preliminary results in PCa suggest that cytoreductive surgery may be an option in some mPCa patients. The lack of randomized controlled trials and the low level of evidence in the current literature preclude any firms conclusion on the benefit of cRP in mPCa. Ongoing phase II and future phase III studies are mandatory to define the exact role of cRP in mPCa and to identify the patients who are most likely to benefit from cRP.

Long-term Outcomes Following Radiation Therapy For Prostate Cancer Patients With Lymph Node Metastases at Diagnosis Treated With and Without Surgery

OBJECTIVES

To evaluate the long-term outcomes for prostate cancer (PCa) patients with lymph node involvement (LNI) treated with radiotherapy at the University of California San Francisco.

MATERIALS AND METHODS

All newly diagnosed PCa patients with LNI treated with radiotherapy as primary therapy or after surgery, each with and without hormonal therapy (HT) between 1988 and 2009 were included.Thirty-five patients (38%) were managed with external beam radiotherapy alone (eRT), 18 patients (20%) with radical prostatectomy (RP)+adjuvant radiotherapy, and 38 patients (42%) with RP+salvage radiotherapy. Overall 82% of the study sample received HT with similar proportions among radiation therapy (RT) subsets (P=0.83).

RESULTS

The median follow-up (FU) was 65, 42, and 86 months for patients treated with eRT, adjuvant radiotherapy, and salvage radiotherapy, respectively.The 10-year estimates from start of primary therapy for patients with LNI for overall survival (OS) was 78% (95% confidence interval [CI], 62%-88%) and for cause-specific survival was 89% (95% CI, 78%-95%). The 5-year estimates from the start of RT for biochemically no evidence of disease was 68% (95% CI, 56%-78%) and for disease-free survival was 67% (95% CI, 54%-77%). There was no difference in any of these outcomes among the 3 RT groups.Patients treated with HT were more likely to have a better 10-year OS (82% vs. 66%; log rank: P=0.001).Multivariate analysis indicated that only age and Gleason score were significant predictors for biochemically no evidence of disease and OS.

CONCLUSIONS

Patients diagnosed with PCa with LNI who were treated with RT with or without a prior surgery had relatively favorable long-term outcomes.

Stratifying prostate cancer patients by relative lymph node involvement: population- and modeling-based study

It is estimated that about 10% of new prostate cancer (PCa) cases are lymph node‐positive (LN+). We have previously discussed the role of the inflection point (IP) of an inverse Gompertzian survival curve as a surrogate for disease incurability. In this study, we aimed to stratify curability of different patient cohorts with pathologically positive lymph nodes through modeling survival curves by different percentages of LN involvement (%LN+) postoperatively and calculating associated IPs. From the Surveillance, Epidemiology, and End Results (SEER) database, we selected LN+ PCa patients undergoing radical prostatectomy. Modeling of relative survival curves using inverse Gompertzian kinetics for increasing value of maximal %LN+ involvement allowed stratification of cohort into groups with <10%, 10–40%, and greater or equal to 40% of LN+ out of all LNs sampled. Data were retrieved for 5903 patients. For the entire cohort, relative survival was 96%, 87%, and 76% at 5, 10, and 15 years, respectively. For %LN +, <10% the IP was about 27 years postoperatively. Patients with 10–40% LN+ had an IP at about 10 years; for those with more than 40% LN+, the IP was 7 years. A 10‐year relative survival decreases from 97% for <10% LN+ to 71% for more than 40% LN+. While better therapies for LN + PCa are badly needed, this patient cadre is not homogenous and should be stratified by %LN+ in future clinical trials.

[Cytoreductive radical prostatectomy for prostate cancer with minimal osseous metastases: results of a first feasibility and case control study]

BACKGROUND

Androgen deprivation therapy (ADT) represents the standard treatment for patients with prostate cancer (PCA) and osseous metastases. We explored the role of cytoreductive radical prostatectomy in PCA with low volume skeletal metastases in terms of a feasibility study.

MATERIAL AND METHODS

A total of 23 patients with biopsy proven PCA, minimal osseous metastases (≤3 hot spots on bone scan), absence of visceral or extensive lymph node metastases and a decrease in prostate-specific antigen (PSA) to <1.0 ng/ml after neoadjuvant ADT were included in the feasibility study (group A). The control group (group B) consisted of 38 men with metastatic PCA who were treated by ADT alone. Surgery-related complications, time to castration resistance, symptom-free, cancer-specific and overall survival were analyzed using descriptive statistical analyses.

RESULTS

The mean age was 61 years (range 42-69 years) and 64 years (47-83) in groups A and B, respectively, with similar patient characteristics in terms of initial PSA level, biopsy Gleason score, clinical stage and extent of metastatic disease. The median follow-up was 34.5 months (7-75 months) and 47 months (28-96 months) in groups A and B, respectively. Median time to castration resistance was 40 months (9-65 months) and 29 months (16-59 months) in groups A and B, respectively (p=0.04). Patients in group A experienced significantly better clinical symptom-free (38.6 versus 26.5 months, p=0.032) and cancer-specific survival rates (95.6% versus 84.2%, p=0.043) whereas the overall survival was similar. In group A none of the men underwent palliative surgical procedures for locally progressing PCA compared to 29% in group B.

CONCLUSIONS

Cytoreductive radical prostatectomy is feasible in well-selected men with metastatic PCA who responded well to neoadjuvant ADT. These men have a long life expectancy and the risk of locally recurrent PCA and local complications are reduced. Cytoreductive radical prostatectomy might be a treatment option in the multimodal management of PCA with minimal osseous metastases.

"Hit the primary": A paradigm shift in the treatment of metastatic prostate cancer?

Patients with metastatic prostate cancer (PC) represent a heterogeneous group with survival rates varying between 13 and 75 months. The current standard treatment in this setting is hormonal therapy, with or without docetaxel-based chemotherapy. In the era of individualized medicine, however, maximizing treatment options, especially in long-term surviving patients with limited disease burden, is of capital importance. Emerging data, mainly from retrospective surgical series, show survival benefits in men diagnosed with metastatic PC following definitive therapy for the prostate. Whether the irradiation of primary tumor in a metastatic disease might improve the therapeutic ratio in association with systemic treatments remains investigational. In this scenario, modern radiation therapy (RT) can play a significant role owing to its intrinsic capability to act as a more general immune response modifier, as well as to the potentially better toxicity profile compared to surgery. Preclinical data, clinical experience, and challenges in local treatment in de novo metastatic PC are reviewed and discussed.

Comparison of semi-extended and standard lymph node dissection in radical prostatectomy: A single-institute experience

Standard lymphadenectomy for prostate cancer is limited to the obturator lymph nodes (LNs), although the internal and external iliac LNs represent the primary landing zone for prostatic lymphatic drainage. We performed anatomically semi-extended pelvic lymph node dissection (PLND) to assess the incidence of LN metastasis in cases of clinically localized prostate cancer. A total of 730 consecutive patients underwent radical prostatectomy with either semi-extended PLND, comprising 6 selective fields, namely the external iliac, internal iliac and obturator LNs bilaterally, or standard LND (obturator LNs alone). A total of 131 patients undergoing semi-extended PLND were compared with 599 patients undergoing standard LND. The patients were stratified into high-risk [prostate-specific antigen (PSA)>20 ng/ml, Gleason score (GS)≥8], intermediate-risk (PSA 10-20 ng/ml, GS=4+3) and low-risk (PSA<10 ng/ml, GS≤3+4) subgroups. Following semi-extended LND, positive LNs were detected in 12/61 (20%) of the high-risk, 1/30 (3%) of the intermediate-risk and 0/40 (0%) of the low-risk cases. Following standard LND, positive LNs were detected in 13/182 (7%) of the high-risk, 1/164 (0.6%) of the intermediate-risk and 0/253 (0%) of the low-risk cases. In high-risk patients, the detection rate of LN metastasis was significantly higher following extended LND compared with standard LND (P<0.01). In 9 of 13 patients (69%), metastases were identified in the internal and external iliac regions, despite negative obturator LNs. There were no significant differences regarding intraoperative and postoperative complications or blood loss in the two groups. There was no lymphocele formation in patients undergoing either standard or semi-extended LND. Extended pelvic LND (PLND) is associated with a high rate of LN metastasis detection outside the fields of standard LND in cases with clinically localized prostate cancer. Therefore, LND including the internal and external iliac LNs should be performed in all patients with high-risk prostate cancer; however, in the low-risk group, PLND may be omitted.

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.

Cytoreductive radical prostatectomy in patients with prostate cancer and low volume skeletal metastases: results of a feasibility and case-control study

PURPOSE

Androgen deprivation represents the standard treatment for prostate cancer with osseous metastases. We explored the role of cytoreductive radical prostatectomy in prostate cancer with low volume skeletal metastases in terms of a feasibility study.

MATERIALS AND METHODS

A total of 23 patients with biopsy proven prostate cancer, minimal osseous metastases (3 or fewer hot spots on bone scan), absence of visceral or extensive lymph node metastases and prostate specific antigen decrease to less than 1.0 ng/ml after neoadjuvant androgen deprivation therapy were included in the feasibility study (group 1). A total of 38 men with metastatic prostate cancer who were treated with androgen deprivation therapy without local therapy served as the control group (group 2). Surgery related complications, time to castration resistance, and symptom-free, cancer specific and overall survival were analyzed using descriptive statistical analysis.

RESULTS

Mean patient age was 61 (range 42 to 69) and 64 (range 47 to 83) years in groups 1 and 2, respectively, with similar patient characteristics in terms of initial prostate specific antigen, biopsy Gleason score, clinical stage and extent of metastatic disease. Median followup was 34.5 months (range 7 to 75) and 47 months (range 28 to 96) in groups 1 and 2, respectively. Median time to castration resistant prostate cancer was 40 months (range 9 to 65) and 29 months (range 16 to 59) in groups 1 and 2, respectively (p=0.04). Patients in group 1 experienced significantly better clinical progression-free survival (38.6 vs 26.5 months, p=0.032) and cancer specific survival rates (95.6% vs 84.2%, p=0.043), whereas overall survival was similar. Of the men in groups 1 and 2, 20% and 29%, respectively, underwent palliative surgical procedures for locally progressing prostate cancer.

CONCLUSIONS

Cytoreductive radical prostatectomy is feasible in well selected men with metastatic prostate cancer who respond well to neoadjuvant androgen deprivation therapy. These men have a long life expectancy, and cytoreductive radical prostatectomy reduces the risk of locally recurrent prostate cancer and local complications. Cytoreductive radical prostatectomy might be a treatment option in the multimodality management of prostate cancer with minimal osseous metastases.

Primary treatment of the prostate improves local palliation in men who ultimately develop castrate-resistant prostate cancer

OBJECTIVES

To determine whether local treatment of primary prostate cancer gives palliative benefit to men who later develop castrate-resistant prostate cancer (CRPC). Local treatments of primary prostate cancer are defined as radical retropubic prostatectomy (RRP) or external beam radiation therapy (EBRT).

PATIENTS AND METHODS

Patient records were reviewed in five different hospitals in Sydney, Australia, and 263 men with CRPC were identified. Eligible patients comprised men who had progressive disease during androgen deprivation therapy with castrate levels of testosterone. Clinical and pathological data were reviewed and evaluated using the chi-squared test and relative risk analysis to determine the relationship between previous local prostate treatment and complications secondary to local disease. The end-point was complications and morbidity attributed to cancer progression locally (i.e. from the prostate).

RESULTS

Primary treatment of the prostate by either RRP or EBRT significantly reduces the incidence of local complications compared to no primary treatment (32.6% vs 54.6%; P = 0.001). RRP showed a significantly lower level of local complications compared to EBRT (20.0% vs 46.7%; P = 0.007). The most common local complications were bladder outlet obstruction (35.0%) and ureteric obstruction (15.2%).

CONCLUSIONS

The present retrospective analysis supports the hypothesis that primary local prostatic treatment gives palliative benefit to men who later develop CRPC. RRP was associated with the lowest local complication rate experienced at the stage of metastatic disease.

Pathological features of lymph node metastasis for predicting biochemical recurrence after radical prostatectomy for prostate cancer

PURPOSE

Subclassification of nodal stage may have prognostic value in men with lymph node metastasis at radical prostatectomy. We explored the role of extranodal extension, size of the largest metastatic lymph node and the largest metastasis, and lymph node density as predictors of biochemical recurrence.

MATERIALS AND METHODS

We reviewed pathological material from 261 patients with node positive prostate cancer. We examined the predictive value when adding the additional pathology findings to a base model including extraprostatic extension, seminal vesicle invasion, radical prostatectomy Gleason score, prostate specific antigen and number of positive lymph nodes using the Cox proportional hazards regression and Harrell concordance index.

RESULTS

The median number of lymph nodes removed was 14 (IQR 9, 20) and the median number of positive lymph nodes was 1 (IQR 1, 2). At a median followup of 4.6 years (IQR 3.2, 6.0) 155 of 261 patients experienced biochemical recurrence. The mean 5-year biochemical recurrence-free survival rate was 39% (95% CI 33-46). Median diameter of the largest metastatic lymph node was 9 mm (IQR 5, 16). On Cox regression radical prostatectomy specimen Gleason score (greater than 7 vs 7 or less), number of positive lymph nodes (3 or greater vs 1 or 2), seminal vesicle invasion and prostate specific antigen were associated with significantly increased risks of biochemical recurrence. On subset analysis metastasis size significantly improved model discrimination (base model Harrell concordance index 0.700 vs 0.655, p = 0.032).

CONCLUSIONS

Our study confirms that the number of positive lymph nodes is a predictor of biochemical recurrence in men with node positive disease. The improvement in prognostic value of measuring the metastatic focus warrants further investigation.

Lymph node-positive prostate cancer: current issues, emerging technology and impact on clinical outcome

Lymph node metastasis in patients with prostate cancer indicates a poorer prognosis compared with patients without lymph node metastasis; however, some patients with node-positive disease have long-term survival. Many studies have attempted to discern what characteristics of lymph node metastasis are prognostically significant. These characteristics include nodal tumor volume, number of positive lymph nodes, lymph node density, extranodal extension, lymphovascular invasion and tumor dedifferentiation. Favorable characteristics of regional lymph node involvement included a smaller tumor size and smaller tumor volume. However, the current staging system for prostate cancer does not provide different subclassifications for patients with node-positive prostate cancer. In recent years numerous advanced technologies for the detection of lymph node metastasis have been developed, including molecular imaging techniques and the CellSearch Circulating Tumor Cell System. With the increased detection of patients with prostate cancer, emergence of new technology to identify lymph node metastasis and the number of radical prostatectomies being performed on the rise, subclassifying patients with lymph node-positive disease is imperative. Subclassification would provide a better picture of patient prognosis and allow for a better understanding of targeted therapies to treat patients with lymph node metastasis.

A review of high-risk prostate cancer and the role of neo-adjuvant and adjuvant therapies

High-risk, localized prostate cancer represents a complex and diverse disease with many available treatment modalities. Patients are often deemed high risk because they are at increased risk for biochemical failure after primary intervention. However, these "high-risk" men may not be at significant risk of dying from their cancer. In this review, an attempt will be made to better define high-risk patients and help identify men at increased risk for mortality, not simply biochemical failure, after a diagnosis of localized prostate cancer. A review of available monotherapies as well as previously successful multimodality treatments will also be presented. Finally, this review will provide a glimpse into the future direction of high-risk prostate cancer multimodal therapy by providing a synopsis several current randomized clinical trials using effective systemic adjuvant therapies following local treatment.

Histopathological characteristics of lymph node metastases predict cancer-specific survival in node-positive prostate cancer

OBJECTIVE

To correlate the histopathological characteristics of lymph node metastases in prostate cancer with cancer-specific survival (CSS).

PATIENTS AND METHODS

The histopathological slides from 142 patients who had had a pelvic lymph node dissection for node-positive prostate cancer were reviewed. For each patient we recorded the number of lymph nodes removed, the number of positive nodes, the diameter of the largest metastasis and extranodal extension (ENE). The lymph node metastases were graded according to the Gleason system. These variables were correlated with CSS.

RESULTS

The mean age of the patients was 62.4 years and the mean preoperative prostate-specific antigen level was 40.2 ng/mL. The median follow-up was 77.5 months, and the median overall and CSS were 91 and 112 months, respectively. On univariable analysis the following variables correlated with poor CSS: a nodal Gleason score of >7 (hazard ratio 2.4, P < 0.001), a diameter of the largest metastasis of >3 mm (2.2, P = 0.025), more than two lymph node metastases (2.0, P = 0.003), and ENE in more than one lymph node (1.9, P = 0.014). Multivariable analysis showed only the nodal Gleason score and the diameter of the largest metastasis to be independent predictors of CSS (1.8, P = 0.021, and 2.2, P = 0.046, respectively).

CONCLUSION

The histopathological characteristics of lymph node metastases in prostate cancer have predictive value for the clinical outcome. The nodal Gleason score and the diameter of the largest metastasis are independent predictors of survival.

Anatomical Extent of Pelvic Lymphadenectomy in Patients Undergoing Radical Prostatectomy

OBJECTIVES

The rationale for locoregional staging lymphadenectomy in prostate cancer (pCA) lies in the accurate diagnosis of occult micrometastases to stratify patients who might benefit from adjuvant therapeutic measures. In pCA, the issues of the necessity and the therapeutic advantage of pelvic lymphadenectomy (PLND]) in patients with low-, intermediate-, and high-risk disease are still discussed controversially. The aim of this review manuscript is to critically evaluate the current status on PLND in pCA.

METHODS

A review of the literature was performed concerning radical prostatectomy and PLND with respect to anatomical extent, oncological outcome, and associated complications.

RESULTS

The anatomical lymphatic drainage of the prostate includes the obturator fossa, and the external and internal iliac arteries; therefore, at least these areas should be included in PLND. According to the current clinical studies, extended PLND (ePLND) significantly increases the yield of both total lymph nodes and lymph node metastases independent of the risk classification of pCA. Lymph node metastases will be detected in about 5-6%, 20-25%, and 30-40% of low-, intermediate-, and high-risk pCA, respectively. Exclusively 25% of all positive lymph nodes are located in the area around the internal iliac artery. With regard to progression-free and cancer-specific survival, retrospective analysis of the SEER data and additional case-control studies indicate a direct positive relationship between the number of removed lymph nodes and long-term oncological outcome in patients with limited lymph node involvement or negative lymph nodes. In these patients, cancer-specific survival is improved by about 15-20%. On the basis of results of large case-control studies, complication rates of ePLND are not significantly increased.

CONCLUSIONS

On the basis of current data, the following conclusions can be drawn: (1) If performed, PLND has to be done in the extended, anatomically adequate variant. (2) The frequency of lymph node metastases in low-risk pCA is low, and the issue of PLND has to be discussed with the patient. (3) If radical prostatectomy is performed in intermediate- and high-risk pCA, an ePLND should be option of choice. For the future, ongoing prospective trials have to demonstrate a benefit in terms of biochemical-free and cancer-specific survival.

Choices for Surgery

Surgical treatment of prostate cancer has seen many improvements in the past two decades, including laparoscopy, robotic surgery, and better assessment of quality of life and functional results. The limits of surgery for locally advanced disease and after failure of radiotherapy have been better defined, together with the roles of neoadjuvant and adjuvant treatment. Patients with clinically organ-confined prostate cancer, reasonable life expectancy, and little or no co-morbidity are the best candidates for radical prostatectomy. This chapter reviews the different technical options for the treatment of prostate cancer, with their respective indications and functional and oncological results.

Long-term outcome for lymph node-positive prostate cancer

Although the number of men with lymph node-positive prostate cancer has declined, it is still significant and the challenge remains on how best to treat these patients. Only long-term follow-up can give a true indication of the outcome in prostate cancer. We evaluated our experience in treating lymph node-positive prostate cancer with a median follow-up of 10.2 years. The overall 5-year survival was 78% and the 10-year survival was 56%. Length of tumor control depends on the type of treatment given. Adding androgen ablation improves the duration of control dramatically, although optimal timing is still uncertain.

Is Radical Prostatectomy Feasible in All Cases of Locally Advanced Non-Bone Metastatic Prostate Cancer? Results of a Single-Institution Study

OBJECTIVES

Previous prospective studies of the surgical treatment of locally advanced prostate cancer have enrolled patients selected on the basis of a limited T3 disease extension. The aim of the present study was to assess the feasibility and the oncologic outcome of radical prostatectomy administered to a consecutive unselected series of advanced, non-bone metastatic prostate cancers.

METHODS

Between March 1998 and February 2003 radical prostatectomy was offered at our institution to any patient diagnosed with prostate cancer with no sign of extranodal metastatic disease. Data on morbidity and survival for 51 clinically advanced cases (any T>/=3, N0-N1, or any N1 or M1a disease according to the TNM 2002 classification system) operated on by a single expert surgeon were compared with a series of 152 radical prostatectomies performed during the same period by the same operator for clinically organ-confined disease. Adjuvant treatment was administered according to current guidelines.

RESULTS

The two groups did not differ significantly in surgical morbidity except for blood transfusion, operative time, and lymphoceles, which showed a higher rate in patients with advanced disease. The Kaplan-Meier estimate of overall survival and prostate cancer-specific survival at 7 yr were 76.69% and 90.2% in the advanced disease group and 88.4% and 99.3% in the organ-confined disease group, respectively.

CONCLUSIONS

Even in the scenario of extensive surgical indications up to M1a disease, radical prostatectomy proved to be technically feasible and to have an acceptable morbidity rate compared with organ-confined disease. Our initial survival data strengthen the role for surgery as an essential part in the multimodal approach to treating advanced prostate cancer.

Optimal treatment of locally advanced prostate cancer

The treatment of clinically locally advanced prostate cancer (cT3-4) is subject to controversies. Patients with lymph node metastases as well as patients with overstaged localized and thus curable disease fall into this category. Radical prostatectomy, external beam radiotherapy and early or deferred hormonal therapy are possible treatment options. Multimodal treatment (i.e., a combination of these options) is frequently used. After radical prostatectomy, Gleason score-adjusted disease-specific survival does not differ meaningfully between the tumor stages pT2 and pT3-4. In the case of lymph node metastases after radical prostatectomy, but not in node-negative disease, adjuvant hormonal treatment seems to improve survival. Adjuvant radiotherapy may improve biochemical and local control in locally advanced prostate cancer, a survival benefit has, however, not yet been proven. External beam radiotherapy alone provides unfavourable survival rates in locally advanced prostate cancer. Adjuvant hormonal treatment may improve outcome in this setting. When no curative treatment is chosen, early hormonal treatment seems to provide modest benefit compared with deferred therapy.

Limited Pelvic Lymph Node Dissection at the Time of Radical Prostatectomy Does Not Affect 5-Year Failure Rates for Low, Intermediate and High Risk Prostate Cancer: Results From CaPSURE™

PURPOSE

Limited bilateral pelvic lymph node dissection performed at radical prostatectomy provides staging information that is used to guide further disease management. Given the effects of widespread prostate specific antigen testing and stage migration, most procedures in the United States are performed for low risk disease, which has a low probability (less than 1%) of lymph node metastasis. We compared 5-year treatment failure rates in patients with low, intermediate and high risk disease who underwent radical prostatectomy with or without pelvic lymph node dissection.

MATERIALS AND METHODS

We compared treatment failure rates for radical prostatectomy in 4,693 patients enrolled in the CaPSURE database who underwent radical prostatectomy with or without limited pelvic lymph node dissection. Secondary analysis was performed as a function of pelvic lymph node dissection and risk group based on pretreatment stage, grade and prostate specific antigen. Treatment failure rates were estimated by Kaplan-Meier analysis.

RESULTS

The 5-year failure-free survival rate was 70% in the no pelvic lymph node dissection group and 74% in the limited pelvic lymph node dissection group (p = 0.11), while the rates in the low, intermediate and high risk groups were 81% and 82% (p = 0.83), 71% and 63% (p = 0.21), and 42% and 48% (p = 0.45) in the no vs limited pelvic lymph node dissection groups, respectively. Multivariate analysis demonstrated that pelvic lymph node dissection status was not a predictor of treatment failure (p = 0.93).

CONCLUSIONS

This study demonstrates in a large cohort of patients that limited pelvic lymph node dissection at radical prostatectomy has no effect on treatment failure rates at 5 years in those at low, intermediate and high risk.

Changing Nature of High Risk Patients Undergoing Radical Prostatectomy

PURPOSE

We examined the outcomes of radical prostatectomy alone in high risk patients with prostate cancer and evaluated changes in high risk prostate cancer outcomes with time.

MATERIALS AND METHODS

From 1988 to 2003, 251 men with high risk prostate cancer (prostate specific antigen more than 20 ng/ml and/or biopsy Gleason greater than 7) were identified in a cohort of 1,796 (14%) enrolled in the Shared Equal Access Regional Cancer Hospital Database. Temporal changes in clinicopathological characteristics and prostate specific antigen recurrence rates were examined stratified by 4, 4-year periods.

RESULTS

With time significantly more men were considered at high risk due to a high biopsy Gleason score relative to prior years, when the most common reason for being considered at high risk was increased PSA (p <0.001). Only 3% of high risk men from 2000 to 2003 had increased prostate specific antigen and high biopsy Gleason score compared to 23% from 1988 to 1991. With time there were no differences in biochemical recurrence rates (p = 0.147). Men with a high biopsy Gleason score and increased prostate specific antigen had worse outcomes than men with only a high Gleason score or men with only high prostate specific antigen (p = 0.046 and 0.081, respectively). On multivariate analysis that only included preoperative clinical characteristics only prostate specific antigen was an independent predictor of prostate specific antigen failure following radical prostatectomy (p = 0.014). There was a trend, which did not attain statistical significance, for higher biopsy Gleason scores and higher clinical stage to be associated with higher failure rates (p = 0.060 and 0.081, respectively).

CONCLUSIONS

Patients are designated as high risk by Gleason grade more commonly now than early in the prostate specific antigen era. Outcomes in high risk patients undergoing radical prostatectomy alone have not significantly improved with time. New treatment strategies, such as multimodality therapy, are needed to improve outcomes in high risk patients with prostate cancer.

Treatment of Locally Advanced Prostate Cancer – The Case for Radical Prostatectomy

The treatment of clinically locally advanced prostate carcinoma (stage cT3) remains controversial. One of the main reasons for this controversy results from the substantial staging error attached to the clinical diagnosis cT3 with overstaged T2 tumors and understaged node-positive cases. Treatment options in this situation include radical prostatectomy, external beam radiotherapy, immediate or delayed androgen deprivation treatment and the so-called 'watchful waiting'. Acceptable and often surprisingly good tumor-specific survival rates have been reported for radical prostatectomy in pT3 series--based on good clinical case selection--approaching those of pT2 series. In lymph node-positive pT3 cases, adjuvant hormone deprivation seems to prolong survival which it does not in lymph node-negative pT3 disease. A benefit of adjuvant external beam radiotherapy after radical prostatectomy for pT3 cases in prolonging overall survival has not been shown, despite the fact that it can prevent or delay biochemical and local recurrence. External beam radiotherapy as the only treatment for cT3 disease results in unfavorable tumor-specific survival rates, which can be significantly improved with adjuvant hormonal treatment with LHRH agonists. If, in case of advanced age and/or significant comorbidity, primary hormonal treatment is chosen, early hormonal deprivation therapy seems to offer marginal benefits in survival compared to delayed treatment.

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.

[Treatment of locally advanced prostate cancer]

The management of clinically locally advanced prostate carcinoma (cT3) remains a controversial issue. The clinical stage cT3 consists of a mixture of overstaged T2 carcinomas but also contains lymph node-positive cases. Treatment options consist of radical prostatectomy, external beam radiotherapy, hormonal deprivation (early or delayed) and the so-called watchful waiting. In many cases multimodal therapy is used. Radical prostatectomy in the clinical stage T3 can achieve acceptable tumour-specific survival rates if patients are well selected. In this way, tumour-specific survival rates can be reached for pT3 patients which closely approach those of pT2 cases. In lymph node-positive cases after radical prostatectomy adjuvant hormonal treatment can prolong survival, but not in lymph node-negative cases. A benefit of adjuvant radiotherapy after radical prostatectomy has not been proven. Although it can postpone or prevent biochemical recurrence, it does not prolong overall survival. Treatment of stage cT3 by external beam radiotherapy alone results in unfavourable tumour-specific survival rates. In these cases definite improvement can be achieved by adjuvant androgen deprivation with LHRH analogues. If in case of severe comorbidity or advanced age primary hormonal treatment is chosen, early vs deferred treatment seems to prolong survival marginally.

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.

Prognostic factors and reporting of prostate carcinoma in radical prostatectomy and pelvic lymphadenectomy specimens

This paper, based on the activity of the Morphology-Based Prognostic Factors Committee of the 2004 World Health Organization-sponsored International Consultation, describes various methods of handling radical prostatectomy specimens for both routine clinical use and research purposes. The correlation between radical prostatectomy findings and postoperative failure is discussed in detail. This includes issues relating to pelvic lymph node involvement, detected both at the time of frozen section and in permanent sections. Issues of seminal vesicle invasion, including its definition, routes of invasion and relationship to prognosis, are covered in detail. The definition, terminology and incidence of extra-prostatic extension are elucidated, along with its prognostic significance relating to location and extent. Margins of resection are covered in terms of their definition, the etiology, incidence and sites of positive margins, the use of frozen sections to assess the margins and the relationship between margin positivity and prognosis. Issues relating to grade within the radical prostatectomy specimen are covered in depth, including novel ways of reporting Gleason grade and the concept of tertiary Gleason patterns. Tumor volume, tumor location, vascular invasion and perineural invasion are the final variables discussed relating to the prognosis of radical prostatectomy specimens. The use of multivariate analysis to predict progression is discussed, together with proposed modifications to the TNM system. Finally, biomarkers to predict progression following radical prostatectomy are described, including DNA ploidy, microvessel density, Ki-67, neuroendocrine differentiation, p53, p21, p27, Bcl-2, Her-2/neu, E-cadherin, CD44, retinoblastoma proteins, apoptotic index, androgen receptor status, expression of prostate-specific antigen and prostatic-specific acid phosphatase and nuclear morphometry.

Curage ganglionnaire dans le cancer de la prostate

In clinically Localized prostate cancers, the interest of pelvic Lymphadenectomy is debated. Nevertheless, this intervention provides important information on disease prognosis (number of positive lymph nodes, tumoural volume, and extracapsular perforation of the affected ganglions); information that previously no other technique could provide. However, no consensus exists concerning patients who should benefit from pelvic Lymphadenectomy and on the extent of this intervention. For most surgeons, decision making regarding ganglion curage is based on nomograms. According to these nomograms, patients with a level of prostate specific antigen (PSA) <10 ng/mL and a Gleason score <7 have a very low risk for ganglionic metastases; this is the reason why the benefit of pelvic Lymphadenectomy remains controversial. Besides, most of these nomograms are based upon the results of standard Lymphadenectomy (iliac vein and obturator fossa) with, subsequently, a related risk of imprecision. In addition, potential therapeutic benefit may be expected from extended ganglion curage, despite the fact that this is not clearly documented yet, due to the benign course of the disease. In other tumoural diseases (stomach cancer, breast cancer, colorectal cancer, blade cancer), on the contrary, survival and stage identification depend on the number of removed ganglions, thus on the extent of Lymphadenectomy.

The role of lymphadenectomy in prostate cancer

It has been shown that an adequate lymphadenectomy for exact staging of prostate cancer consists of removal of all the tissue along the external iliac vein, in the obturator fossa and along the internal iliac artery. Morbidity associated with this procedure is low, if certain technical details are respected. This review discusses in detail the indications for lymphadenectomy and the extent of dissection, based on the localization of the positive nodes. The potential therapeutic impact of extended lymph node dissection in men with prostate cancer is also addressed.

Stellenwert der pelvinen Lymphadenektomie beim klinisch lokalisierten Prostatakarzinom

Lymph node dissection remains the only reliable method for exact staging to date. Extended lymphadenectomy including tissue along the external iliac vein, the obturator fossa, and along the internal iliac vessels should be performed in all patients undergoing radical prostatectomy. There is an increasing amount of data suggesting that removal of all diseased nodes, which contain minimal metastatic disease, may have a positive impact on disease-free and, perhaps, on overall survival. Due to the relatively benign course of the disease, longer follow-up periods are still necessary to make a definitive statement.

Local and systemic therapy for patients with metastatic prostate cancer: should the primary tumor be treated?

Data from well-designed, prospective clinical trials are lacking to support treatment of primary tumor in men diagnosed with metastatic prostate cancer. However, a growing body of evidence suggests that treatment of the primary tumor may enhance cancer control and survival in some men. This evidence is examined and recommendations are made for identifying patients with metastatic prostate cancer who may benefit from definitive treatment of the prostate tumor.

Positron emission tomography for prostate, bladder, and renal cancer

Prostate cancer, renal cancer, bladder, and other urothelial malignancies make up the common tumors of the male genitourinary tract. For prostate cancer, common clinical scenarios include managing the patient presenting with 1) low-risk primary cancer; 2) high-risk primary cancer; 3) prostate-specific antigen (PSA) recurrence after apparently successful primary therapy; 4) progressive metastatic disease in the noncastrate state; and 5) progressive metastatic disease in the castrate state. These clinical states dictate the appropriate choice of diagnostic imaging modalities. The role of positron emission tomography (PET) is still evolving but is likely to be most important in determining early spread of disease in patients with aggressive tumors and for monitoring response to therapy in more advanced patients. Available PET tracers for assessment of prostate cancer include FDG, 11C or 18F choline and acetate, 11C methionine, 18F fluoride, and fluorodihydrotestosterone. Proper staging of prostate cancer is particularly important in high-risk primary disease before embarking on radical prostatectomy or radiation therapy. PET with 11C choline or acetate, but not with FDG, appears promising for the assessment of nodal metastases. PSA relapse frequently is the first sign of recurrent or metastatic disease after radical prostatectomy or radiation therapy. PET with FDG can identify local recurrence and distant metastases, and the probability for a positive test increases with PSA. However, essentially all studies have shown that the sensitivity for recurrent disease detection is higher with either acetate or choline as compared with FDG. Although more data need to be gathered, it is likely that these two agents will become the PET tracers of choice for staging prostate cancer once metastatic disease is strongly suspected or documented. 18F fluoride may provide a more sensitive bone scan and will probably be most valuable when PSA is greater than 20 ng/mL in patients with high suspicion or documented osseous metastases. Several studies suggest that FDG uptake in metastatic prostate cancer lesions reflects the biologic activity of the disease. Accordingly, FDG can be used to monitor the response to chemotherapy and hormonal therapy. Androgen receptor imaging agents like fluorodihydrotestosterone are being explored to predict the biology of treatment response for progressive tumor in late stage disease in castrated patients. The assessment of renal masses and primary staging of renal cell carcinoma are the domain of helical CT. PET with FDG may be helpful in the evaluation of "equivocal findings" on conventional studies, including bone scan, and also in the differentiation between recurrence and posttreatment changes. The value of other PET tracers in renal cell carcinoma is under investigation. Few studies have addressed the role of PET in bladder cancer. Because of its renal excretion, FDG is not a useful tracer for the detection of primary bladder tumors. The few studies that investigated its role in the detection of lymph node metastases at the time of primary staging were largely disappointing. Bladder cancer imaging with 11C choline, 11C methionine, or 11C- acetate deserves further study.

PROSTATE SPECIFIC ANTIGEN PROGRESSION IN MEN WITH LYMPH NODE METASTASES FOLLOWING RADICAL PROSTATECTOMY: RESULTS OF LONG-TERM FOLLOWUP

PURPOSE

We examined the clinical outcome of patients with lymph node metastases found at prostatectomy with the goal to identify factors that predict freedom from prostate specific antigen (PSA) progression.

MATERIALS AND METHODS

We retrospectively reviewed the records of 3,264 consecutive men with clinically localized prostate cancer who underwent extended pelvic lymphadenectomy and radical prostatectomy performed by a single surgeon between April 1982 and March 2003. Patients with pathologically confirmed lymph node metastases and no history of adjuvant treatment were identified. Clinical and histopathological factors were analyzed for an association with time to PSA progression using univariate and multivariable analyses.

RESULTS

Of the 143 patients (4.4% of total) in the study with nodal involvement 24 (16.8%) were free of disease at last followup (median 6 years). Median time to failure was 2 years with PSA progression occurring as late as 11 years postoperatively in 2 patients. The 5 and 7-year PSA progression free rate in all lymph node positive patients was 26.5% and 10.9%, respectively. A 15% or greater incidence of positive nodes (p = 0.0008) and high prostatectomy Gleason score (ie score 8 to 10, p = 0.008) were independent predictors of PSA progression in multivariate Cox proportional hazards models. Seminal vesicle invasion (HR 1.45, p = 0.063) or positive surgical margins (HR 1.43, p = 0.063) were marginally significant in the multivariate model. The 5-year PSA progression-free rate was 52% in men with less than 15% positive lymph nodes, prostatectomy Gleason score 7 or less and negative seminal vesicle invasion.

CONCLUSIONS

While the incidence of lymph node positive disease in patients undergoing radical prostatectomy is infrequent in the PSA era, patients with nodal involvement may experience disease progression as remote as 1 decade after surgery. Pathological factors such as the percent of positive lymph nodes, prostatectomy Gleason score and seminal vesicle invasion appear to predict an increased risk of PSA failure in this population.

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.

Disease progression and survival of patients with positive lymph nodes after radical prostatectomy. Is there a chance of cure?

PURPOSE

In prostate cancer involvement of regional lymph nodes is regarded as a poor prognostic factor. Is this also true for micrometastasis if a meticulous lymph node dissection is performed? We determined progression rate and survival of patients with positive nodes following radical prostatectomy according to the number of metastases.

MATERIALS AND METHODS

Between 1989 and 1999, 367 patients with clinically organ confined prostate cancer underwent meticulous pelvic lymph node dissection and radical prostatectomy. None of the patients received immediate adjuvant therapy.

RESULTS

Of the patients 92 (25%) had histologically proven lymph node metastases. Followup of more than 1 year was available in 88 patients (96%), and median followup was 45 months (range 13 to 141). Of 19 patients (22%) who died of prostate cancer 16 had more than 1 positive node. Of the 39 patients with only 1 positive node 15 (39%) remained without signs of clinical or chemical progression. Whereas of the 20 and 29 patients with 2 or more positive lymph nodes only 2 (10%) and 4 (14%), respectively, remained disease-free. Time to prostate specific antigen relapse, symptomatic progression and tumor related death were significantly affected by the number of positive nodes.

CONCLUSIONS

Meticulous lymph node dissection reveals a high rate of metastases (25%). In patients with positive nodes time to progression is significantly correlated with the number of diseased nodes. Some patients with minimal metastatic disease remain free of prostate specific antigen relapse for more than 10 years after prostatectomy without any adjuvant treatment. Meticulous pelvic lymph node dissection, particularly in patients with micrometastases, seems not only to be a staging procedure, but may also have a positive impact on disease progression and long-term disease-free survival.