Intermediate-term survival results in clinically understaged prostate cancer patients following radical prostatectomy

Pattern of prostate cancer presentation among the Egyptian population: A study in a single tertiary care center

INTRODUCTION

Prostate cancer is a common health problem that in the majority of cases starts to develop at the age of 50 years, reaching its peak at 60-70 years of age. A variation in its incidence and prevalence exists between western, Asian and Arabic populations. The aim of our work was to report the pattern of prostate cancer presentation in Alexandria University that as a tertiary referral center provides care for uro-oncology cases.

MATERIAL AND METHODS

Data collection for all patients diagnosed with prostate cancer at Alexandria University in Egypt through the year 2012 was done.

RESULTS

The mean age of the patients was 67. Mean serum total PSA, prostate volume and PSAd were 149 ng/ml, 63 grams and 3.1 ng/ml/gm respectively. 25% of patients were asymptomatic diagnosed accidentally during screening for prostate cancer. The remaining group was presenting with LUTS, including 23 patients who presented initially with back pain.

CONCLUSIONS

Egyptian men with prostate cancer have a markedly high PSA density and Gleason grade at diagnosis.

Role of pelvic lymph node dissection in prostate cancer treatment

Pelvic lymph node dissection (PLND) is the most accurate and reliable staging procedure for detecting lymph node invasion (LNI) in prostate cancer. Recently, [(11)C]-choline positron emission tomography imaging and magnetic resonance imaging with lymphotropic superpara-magnetic nanoparticles have shown potential for detecting LNI but are still under investigation. The risk of LNI in low-risk groups could be underestimated by use of the current nomograms, which rely on data collected from patients who underwent only limited PLND. Extended PLND (ePLND) shows higher lymph node yield, which leads to the removal of more positive nodes and fewer missed positive nodes. It may be possible to refrain from performing PLND on low-risk patients with a prostate-specific antigen value <10 ng/ml and a biopsy Gleason score ≤6, but the risk of biopsy-related understaging should be kept in mind. Theoretically, meticulous ePLND may also impact prostate cancer survival by clearing low-volume diseases and occult micrometastasis even in pN0. The therapeutic role of PLND in prostate cancer patients is still an open question, especially in individuals with low-risk disease. Patients with intermediate- to high-risk disease are more likely to benefit from ePLND.

Complete PSA Remission without Adjuvant Therapy after Secondary Lymph Node Surgery in Selected Patients with Biochemical Relapse after Radical Prostatectomy and Pelvic Lymph Node Dissection

Introduction. To evaluate whether secondary resection of lymph node (LN) metastases (LNMs) can result in PSA remission, we analysed the PSA outcome after resection of LNM detected on PET/CT in patients with biochemical failure. Materials and Methods. 11 patients with PSA relapse (mean 3.02 ng/mL, range 0.5-9.55 ng/mL) after radical prostatectomy without adjuvant therapy were included. Suspicious LN (1-3) detected on choline PET/CT and nearby LN were openly dissected (09/04-02/11). The PSA development was examined. Histological and PET/CT findings were compared. Results. 9 of 10 patients with histologically confirmed LNM showed a PSA response. 4 of 9 patients with single LNM had a complete permanent PSA remission (mean followup 31.8, range 1-48 months). Of metastasis-suspicious LNs (14) 12 could be histologically confirmed. The additionally removed 25 LNs were all correctly negative. Conclusions. The complete PSA remissions after secondary resection of single LNM argue for a feasible therapeutic benefit without adjuvant therapy. For this purpose the choline PET/CT is in spite of its limitations currently the most reliable routinely available diagnostic tool.

Lymph node assessment and lymphadenectomy in prostate cancer

The role of lymph node assessment for patients with clinically localized prostate cancer has significantly evolved over the last 20 years. The status of pelvic lymph nodes primarily served as a prognostic marker for prostate cancer. Improved methods in assessing the risk for cancer progression and metastasis have enhanced our ability to identify patients who require pelvic lymphadenectomy during radical prostatectomy. The status of pelvic lymph nodes is also being used to guide further treatments after surgery. Also, recent data has shown possible therapeutic benefit of lymphadenectomy in improving cancer specific survival.

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.

Limitations of Radioguided Surgery in High-Risk Prostate Cancer

OBJECTIVES

To determine how many men with high-risk prostate cancer (prostate-specific antigen [PSA]>20 ng/ml or biopsy Gleason score 8-10) have positive lymph nodes (sentinel lymph nodes [SLNs] and nonsentinel lymph nodes [NSLNs]) and whether these positive nodes are localised in the region of SLN dissection or in other regions, too.

METHODS

In 228 men with high-risk prostate cancer radical retropubic prostatectomy combined with radioguided pelvic lymph node dissection and extended lymphadenectomy were performed. Serial sections of the SLNs were analysed immunohistochemically.

RESULTS

A median of 7 SLNs (mean, 7) and 11 NSLNs (mean, 11) were dissected per patient. Ninety-six of 228 men (42.1%) had lymph node metastases. Most men had positive lymph nodes along the internal iliac artery alone or in combination with other regions. Twenty-two men had only micrometastatic disease. In 94 of 96 men the SLNs were positive. Twenty-six of 96 men had also positive NSLNs. When SLNs and NSLNs were positive, in more than half the patients the NSLNs were localised outside the region of sentinel lymphadenectomy.

CONCLUSIONS

The dissection of SLNs in prostate cancer has a high sensitivity in detecting positive nodes. When SLNs are negative, the other pelvic lymph nodes are also negative in a high percentage of men (sensitivity 97.1%). When the SLNs are positive, patients with high-risk disease also have a high incidence of positive NSLNs. Therefore, when it is aspired to remove all pelvic lymph node metastases sentinel and extended lymphadenectomy should be performed.

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.

[Sentinel lymph node dissection in prostate cancer. Experience after more than 800 interventions]

There is no consensus on which prostate cancer patients should undergo lymph node removal and which lymph nodes should be included. Therefore, most clinicians rely on nomograms and dispense with lymph node dissection in patients with low-risk disease. Meanwhile, there are some studies which prove that there are also lymph node metastases in patients with low-risk prostate cancer and that lymph node metastases are predominantly localized outside the region of standard lymphadenectomy. In more than 800 men we could show that lymph node metastases were found more often than shown in the Partin tables. These lymph node metastases were detected by sentinel lymph node dissection outside the region of standard and extended lymphadenectomy. Because of insufficient preoperative diagnostics it is unclear which patients have positive lymph nodes. Therefore, it is useful to perform lymph node dissection in every patient. Men with positive nodes could have a better prognosis, when sentinel and extended lymph node dissection are performed.

Role of lymphadenectomy in clinically organ-confined prostate cancer

There has been considerable debate about the utility of pelvic lymph node dissection (PLND) when performing a radical prostatectomy. Reported practices vary from those who always perform an extended PLND to those who employ a predictive nomogram in their decision making to those who are increasingly not performing a PLND in low-risk disease. A Medline search was used to identify relevant manuscripts dealing with the role of lymphadenectomy in clinically organ-confined prostate cancer. A greater number of lymph nodes (LN) removed and examined at prostatectomy for prostate cancer appears to increase the likelihood of finding LN metastases and increase prostate cancer-specific survival even in patients who have histologically uninvolved LN. This survival benefit may result from more accurate staging and possible removal of occult metastases. The need for and extent of PLND in prostate cancer, especially in low-risk disease, however, is unlikely.

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.

Incidence of positive pelvic lymph nodes in patients with prostate cancer, a prostate-specific antigen (PSA) level of < or =10 ng/mL and biopsy Gleason score of < or =6, and their influence on PSA progression-free survival after radical prostatectomy

OBJECTIVE

To investigate how many men with low-risk prostate cancer had positive lymph nodes detected by radio-guided surgery and whether they had a higher biochemical relapse rate after radical prostatectomy, because in such patients most urologists dispense with operative lymph node staging, as nomograms indicate only a low percentage of lymph node metastases.

PATIENTS AND METHODS

The study included 474 men with a prostate-specific antigen (PSA) level of < or = 10 ng/mL, biopsy Gleason score of < or = 6 and positive biopsies in one (group 1, 315 men) or both lobes (group 2, 159 men); follow-up data were available in 357 men. Men with adjuvant radiation or hormone therapy before the occurrence of biochemical relapse were excluded.

RESULTS

Positive lymph nodes were detected in 17 men in group 1, and in 18 in group 2. In more than half of the patients (19/35) these nodes were found outside the region of standard lymphadenectomy. Men with node-positive disease had a higher biochemical relapse rate (P < 0.001). When the tumour was organ-confined and well differentiated in node-positive disease (Gleason score < or = 6) the biochemical relapse rate was lower than in men with higher tumour stage and grade.

CONCLUSIONS

When dissecting pelvic lymph nodes, extended or sentinel lymphadenectomy should be preferred. Removing the diseased nodes could improve the PSA progression-free survival, especially in well differentiated organ-confined disease.

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.

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.

Cancer progression and survival rates following anatomical radical retropubic prostatectomy in 3,478 consecutive patients: long-term results

PURPOSE

We updated a long-term cancer control outcome in a large anatomical radical retropubic prostatectomy (RRP) series. We also evaluated the perioperative parameters that predict cancer specific outcomes following surgery.

MATERIALS AND METHODS

From May 1983 to February 2003, 1 surgeon (WJC) performed RRP in 3,478 consecutive men. Patients were followed with semiannual serum prostate specific antigen (PSA) tests and annual digital rectal examinations. We used Kaplan-Meier product limit estimates to calculate actuarial 10-year probabilities of biochemical progression-free survival, cancer specific survival and overall survival. Multivariate Cox proportional hazards models were used to determine independent perioperative predictors of cancer progression.

RESULTS

At a mean followup of 65 months (range 0 to 233) actuarial 10-year biochemical progression-free, cancer specific and overall survival probabilities were 68%, 97% and 83%, respectively. On multivariate analysis biochemical progression-free survival probability was significantly associated with preoperative PSA, clinical tumor stage, Gleason sum, pathological stage and treatment era. Cancer specific survival and overall survival rates were also significantly associated with clinicopathological parameters.

CONCLUSIONS

RRP can be performed with excellent survival outcomes. Favorable clinicopathological parameters and treatment in the PSA era are associated with improved cancer control.

A randomised trial of periprostatic local anaesthetic for transrectal biopsy

Increasingly transrectal ultrasound and biopsy is performed for the detection of prostate cancer. We have conducted a randomised trial to evaluate whether the addition of periprostatic local anaesthetic injection reduces the discomfort of the procedure. A total of 64 patients who attended a specialised prostate clinic and were being evaluated for an elevated prostate-specific antigen agreed to participate in the trial and were randomly allocated to two groups. The intervention group received 10 ml of 1% lignocaine in the periprostatic tissue prior to biopsy and the control group underwent a standard biopsy. All patients had a sextant biopsy under ultrasound guidance. After the procedure, they were asked to determine the severity of the pain on a scale of 0-10 and the whether the quality of the pain was mild, moderate or severe. The responses were distributed normally. The groups were compared using Student's t-test. Pain severity showed no significant difference between the two groups (P=0.14). There was a trend towards a statistical difference (P=0.07) on the qualitative pain scale. In conclusion, no significant difference in overall discomfort in men having sextant biopsies was detected between the two groups, suggesting that the administration of local anaesthetic may not be as valuable as early reports have suggested.

High serum prostate-specific antigen levels in the absence of prostate cancer in Middle-Eastern men: the clinician's dilemma

OBJECTIVE

To investigate the common causes of total serum prostate-specific antigen (PSA) values of> 10 ng/mL in an Arab population, as in the USA and Europe the risk of prostate cancer is considered high in men with such PSA levels.

PATIENTS AND METHODS

Serum total PSA was measured in men presenting to our hospital as part of the investigation for prostate cancer screening and/or in elderly men with prostatism. Men with a serum PSA level of> 10 ng/mL were further investigated by transrectal ultrasonography (TRUS) of the prostate and biopsy of suspicious lesions for histological diagnosis. In addition, the percentage of free PSA, PSA velocity and PSA density were determined. All the patients included in this study were men of Arab origin residing in Kuwait.

RESULTS

In all, 1700 men (mean age 55.6 years, range 35-94) were assessed; of these, 161 had a serum PSA of> 10 ng/mL, attributable to benign prostatic hyperplasia (BPH) in 110 (68%), BPH with histological features of prostatitis in 33 (21%) and prostate cancer in 18 (11%). TRUS of the prostate in 143 of the 161 men with either BPH or BPH with prostatitis showed varying grades of intraprostatic calcifications in 22 (15%). Both PSA density and percentage free PSA did not contribute to determining the causes of total PSA levels of> 10 ng/mL. There was a progressive decline in PSA in all patients with BPH and prostatitis, except one who at re-biopsy had prostate cancer (T1N0M0, G1).

CONCLUSION

Total PSA values of> 10 ng/mL in Arab men may be a result of BPH, BPH with prostatitis or prostate cancer, in that order. A gradual decline in total PSA (decreased PSA velocity) with time to < 4 ng/mL often confirms the diagnosis of BPH with prostatitis. The percentage of free PSA and PSA density may not be helpful in diagnosing prostate cancer with certainty in these patients. Compared with Caucasians in the USA and Europe, BPH and BPH with prostatitis appear to be more frequent causes of serum PSA levels of> 10 ng/mL in Arab men.

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.

Is a limited lymph node dissection an adequate staging procedure for prostate cancer?

PURPOSE

Generally lymph node dissection is only considered a staging procedure for prostate cancer. Therefore, the need for meticulous lymph node dissection is often questioned and only sampling is suggested. We performed a prospective study to identify the pattern of lymph node metastasis in prostate cancer and determine how extensive lymph node dissection must be not to under stage cases.

MATERIALS AND METHODS

All patients with clinically organ confined prostate cancer, no prior hormonal treatment, negative preoperative staging computerized tomography and bone scan, who underwent radical prostatectomy between 1989 and 1999, were evaluated prospectively as to the number and location of lymph node metastasis. A meticulous lymph node dissection was performed along the external iliac vein, obturator nerve and internal iliac (hypogastric) vessels. Nodes from each location and side were submitted separately for histological evaluation.

RESULTS

In 365 patients with a median serum prostate specific antigen of 11.9 ng./ml. (range 0.4 to 172) the median number of nodes removed was 21 (range 6 to 50). Lymph nodes were positive in 88 (24%) patients and the median number of positive nodes was 2 (range 1 to 19). Internal iliac lymph nodes were positive in 51 (58%) of the 88 patients, including 34 with additional positive lymph nodes along the external iliac vein and/or obturator nerve. Internal iliac lymph nodes alone were positive in 17 (19%) of 88 patients.

CONCLUSIONS

There were significant numbers of lymph node metastases at all 3 different areas of lymphadenectomy. Positive lymph nodes were found along the internal iliac artery in more than half (58%) of the patients and exclusively in 19%. Therefore, we consider lymph node dissection along the internal iliac (hypogastric) vessels essential for representative staging. Without this dissection a fifth of node positive cases would have been under staged and diseased nodes would have remained in more than half of the cases.

Results of laparoscopic pelvic lymphadenectomy in patients at high risk for nodal metastases from prostate cancer

BACKGROUND

Laparoscopic pelvic lymphadenectomy (LPLND) can be performed safely and with minimal morbidity in the staging of prostate cancer. Its utility in evaluating patients at high risk for metastatic disease before primarily nonsurgical treatment modalities was evaluated.

METHODS

Twenty-four consecutive patients who underwent LPLND between June 1993 and July 1996 were studied. These patients were considered poor surgical candidates based on several risk factors, as follows: elevation of serum PSA >20 in 19 patients (79%); elevation of serum acid phosphatase in 4 patients (17%); digital rectal examination findings indicative of extraprostatic extension or seminal vesical involvement in 14 patients (58%); and poorly differentiated tumors on prostate biopsy in 19 patients (79%). Nineteen patients (79%) had two or more of these risk factors. Median PSA for the entire series of patients was 35.2 ng/mL (range 7.9 to 133 ng/mL), and median Gleason score was 7 (range 5 to 9). Preoperative CT or MRI was negative for pelvic lymph node metastases in 17 of 23 patients (79%), and bone scan was negative in all 24 patients.

RESULTS

Unilateral (n = 2) or bilateral (n = 22) LPLND was performed in all patients. Six patients (25%) had lymph node metastases detected laparoscopically. Five of the six patients had palpable extraprostatic extension (T3a/b) or invasion of a seminal vesical (T3c), and in four of these patients the site of the metastatic lymph nodes was ipsilateral to the palpable prostate abnormality. None of the risk factors was independently predictive of lymph node metastases within this series of patients. An average of 10.8 +/- 6.5 lymph nodes was removed at a mean operative time of 174 +/- 10 minutes for patients undergoing bilateral LPLND. Estimated blood loss was minimal for 20 of 22 patients (92%) undergoing LPLND alone, and there were no complications requiring open exploration. Mean postoperative hospital stay was 1.2 +/- 0.5 days for patients undergoing LPLND alone.

CONCLUSIONS

LPLND can be used efficiently to identify patients with nodal metastases from select high-risk patients. This, in turn, can exclude such patients from noncurative local and regional therapy.

Defining the role of antiandrogens in the treatment of prostate cancer

OBJECTIVES

Although antiandrogens have been used as monotherapy and in combination with other treatment modalities for management of metastatic prostate cancer, their major role to date has been one in which they are used in conjunction with surgical or medical castration for treatment of Stage D (T4/Nx/M1) carcinoma of the prostate. The widespread use of prostate-specific antigen (PSA) is increasing the number of men who are diagnosed with earlier stages of this disease, thus resulting in a greater number of definitive therapeutic procedures. Also, PSA has become the primary modality for following these patients after definitive treatment. Because the use of PSA results in the discovery of lower volume of disease and in discerning earlier recurrence of disease, the question arises as to whether an antiandrogen alone could be an adequate treatment in both neoadjuvant and adjuvant settings.

METHODS

As data accumulate that point to the efficacy of combined androgen blockade in metastatic disease, a protocol has been developed to test the hypothesis of intermittent combined treatment in patients who present with minimal disease and good performance status. In this study, the antiandrogen bicalutamide will be used in combination with the luteinizing hormone-releasing hormone (LHRH) analogue goserelin acetate. Also, short-term combined androgen ablation continues to be investigated prior to both radiation therapy and radical prostatectomy for localized disease.

RESULTS

Two groups of patients are ideal candidates for the use of antiandrogen monotherapy following radical prostatectomy: those whose PSA values do not fall to undetectable levels and the far larger group of men who have capsular penetration or positive surgical margins with nondetectable PSA levels. Protocols have been developed to assess the clinical potential of bicalutamide as the sole adjuvant therapy in these postprostatectomy patients, based in no small part on the relative paucity of side effects of this antiandrogen.

CONCLUSIONS

Antiandrogens in general, and bicalutamide in particular, are poised to play an increasing role in the treatment of all stages of adenocarcinoma of the prostate. The safety profile of bicalutamide, combined with its long half-life, resulting in once-a-day dosing, makes it an ideal choice for clinical trials evaluating an antiandrogen, either alone or combined with reversible medical castration, in earlier stages of prostate cancer as well as in various combination regimens in metastatic disease.

Transrectal ultrasound-guided transperineal cryoablation in the treatment of prostate carcinoma: preliminary results

PURPOSE

We studied ultrasound-guided percutaneous cryoablation for treatment of prostate carcinoma.

MATERIALS AND METHODS

Our series includes 83 individuals who underwent transrectal ultrasound-guided transperineal percutaneous cryoablation of the prostate. Prostate specific antigen levels, biopsy results and complications were assessed at 3 months.

RESULTS

Of 61 biopsies 8 (13.1%) were positive for carcinoma (half showed stage D disease). Of patients with stages T1 to T3 cancer 92.6% were free of disease at 3 months. Prostate specific antigen levels were significantly decreased by an average of 1.90 ng./ml. (p < 0.05). Major complications were infrequent, including bladder perforation in 1 patient, urethral strictures in 3, bladder outlet obstruction in 2 and partial incontinence in 2. Impotence was frequent but transient.

CONCLUSIONS

Transrectal ultrasound-guided transperineal percutaneous cryoablation of the prostate produces few major complications and appears at 3 months to be effective in eradicating local prostate tumors. Longer followup is required to test the original hypothesis.

Values and Limits of Pelvic Lymphadenectomy

Based on a literature review and their own personal experience, the Authors describe the usefulness of pelvic lymph node dissection in the case of bladder, prostate or penis cancer, and its four main aims: staging, cure, prophylaxis and debulking. While in the case of bladder cancer all the afore-mentioned aims may be taken into consideration, in the case of prostatic cancer only staging is of major importance; in the case of penis cancer, lymph node dissection has clearly defined indications.

Residual disease after radical surgery or radiation therapy for prostate cancer. Clinical significance and therapeutic implications

Radical treatment for prostate cancer aims at complete eradication of tumor. This review of published data makes clear that the goal is less frequently achieved than commonly presumed. Following radical prostatectomy extracapsular disease, carrying a significant risk of local recurrence, is found from 12-68% of the time depending on the clinical tumor stage. Local regrowth is associated with a poorer prognosis. A substantial proportion of patients whose prostate glands are rebiopsied more than 18 months after radiation therapy also have residual tumor. This again predicts for clinical relapse. The likelihood of a positive rebiopsy is dependent on original tumor size and current prostate specific antigen (PSA) levels. Strategies for managing residual disease are critically discussed.

Radical retropubic prostatectomy for localised prostatic carcinoma: a clinical and pathological study of 201 cases

To examine the role of radical retropubic prostatectomy in clinically localised prostatic cancer we reviewed a series of 201 patients all of whom had undergone bilateral pelvic lymphadenectomy. Frozen section showed metastatic pelvic lymph nodes in 13 cases and 6 cases were too locally advanced for operation; prostatectomy was done for the remaining 182. The pathological staging was based on examination of sections of the whole organ. In 109 (60%) the carcinoma was confined to the prostate gland or to the specimen, in 46 (25%) there was carcinomatous growth in the surgical margin, and in 27 (15%) there was invasion of the seminal vesicles. The Gleason score was significantly higher in cases with involvement of the surgical margin or seminal vesicles. There was one operative death (of pulmonary embolism), and the postoperative cardiovascular morbidity was 7%. The incidence of wound infection was 6%, and there were two rectal injuries and three symptomatic lymphoceles. A total of 135/170 evaluable patients (79%) were completely continent postoperatively, and only two developed severe incontinence. Erectile potency was preserved in 24 of 126 (19%). We conclude that radical retropubic prostatectomy is safe and that the complication rate is acceptable. The completeness of the tumour excision seems to be associated with the pathological grade of the tumour.

Predictive value of contralateral biopsies in unilaterally palpable prostate cancer

We studied 153 patients with tumors digitally localized to 1 prostatic lobe with transrectal ultrasound and bilateral biopsy. Of these patients 65 (42%) had tumor in the clinically benign lobe as well as the suspicious lobe. These patients had higher serum prostate specific antigen (PSA) levels (27.7 +/- 28.1 versus 14.3 +/- 16.7 ng./ml., p = 0.0001) than those with negative contralateral biopsies. Radical prostatectomy was done in 57 patients; the 25 with positive bilateral biopsies had larger tumors (6.3 +/- 6.0 versus 2.5 +/- 2.4 cc, p = 0.0008) and a much higher likelihood of capsular penetration into the periprostatic fat (72% versus 28%, p = 0.0025) than the 32 with unilaterally positive biopsies. Patients with bilaterally positive biopsies also were more likely to have nodal disease (8% versus 0%), seminal vesicle invasion (20% versus 6%), positive margins (32% versus 19%) and biochemical (PSA) evidence of recurrence (20% versus 3%), although none of these differences was statistically significant. Of the 25 patients with bilaterally positive biopsies 12 (48%) had nonpalpable extension of tumor into the other lobe; adverse findings and outcomes were concentrated in these patients as opposed to the 13 patients in whom small incidental tumors were sampled by biopsy. Finally, 2 of the 25 patients (8%) with bilaterally positive biopsies had a positive surgical margin in the area of the contralateral neurovascular bundle; this was not observed in any of the 32 patients with unilaterally positive biopsies. These findings demonstrate that contralateral negative biopsies in patients with unilaterally palpable disease predict low volume, localized tumor and a negligible likelihood of surgical margin compromise when using a contralateral nerve-sparing approach. Bilaterally positive biopsies suggest larger tumor volume with a greater likelihood of adverse pathological findings and recurrence.

Mass screening for prostatic carcinoma and therapeutic options

In western countries, prostatic carcinoma is the most frequent neoplasia in the male sex after pulmonary neoplasia. Its early diagnosis is very important. The authors report the results of a screening for prostatic carcinoma effected in some municipalities of the district of Parma (Italy); 28 prostatic carcinomas were diagnosed (1.2% of the examined patients). Twelve patients were submitted to radical nerve-sparing prostatectomy according to Walsh. In all of them, PSA values decreased to values < 1 ngr/ml, confirming the radicality of the operation and few complications occurred. The conclusion of the authors is that nowadays timely radical prostatectomy is the only “definitive” treatment of prostatic carcinoma, allowing a better quality of life, however long it is.

Multivariate analysis of factors predicting local relapse after radical prostatectomy--possible indications for postoperative radiotherapy

Between 1970 and 1983, 273 patients underwent radical surgery (radical prostatectomy--261, radical cystoprostatectomy--12) for newly diagnosed adenocarcinoma of the prostate at Duke University Medical Center and received no adjuvant radiotherapy. A total of 46 patients developed local recurrence. Forty developed local relapse only and six developed simultaneous local and distant failure. The crude local relapse rate was 17% (46/273). The actuarial local failure rate at 5, 10, and 15 years was 12%, 32%, and 35%, respectively. Univariate and multivariate analyses were performed to identify factors predictive of local relapse after radical surgery. Possible prognostic factors analyzed were: age, type of biopsy, use of adjuvant hormonal therapy, histologic grade, histologic involvement of seminal vesicles, positive surgical margins, clinical stage, and elevated acid phosphatase. Factors identified as significant predictors of local relapse by univariate analysis were: poorly differentiated histology (p = 0.0001), seminal vesicle involvement (p = 0.0009), and positive surgical margins (p = 0.0001). An elevated preoperative acid phosphatase was of borderline significance (p = 0.06). On multivariate analysis, poorly differentiated histology (p = 0.0007), positive margins (p = 0.0015), and elevated acid phosphatase (p = 0.0273) were significant predictors of local failure. Seminal vesicle involvement was no longer a significant predictor of local failure. However, on subsequent univariate and multivariate analyses, seminal vesicle involvement was the only significant predictor for the development of distant metastases (p = 0.0019, multivariate). Thus, patients with poorly differentiated tumors, positive surgical margins, or elevated preoperative acid phosphatase are at high risk for local relapse after radical prostatectomy. These patients should be included in future clinical trials studying the role of adjuvant radiotherapy after radical prostatectomy, or offered adjuvant radiotherapy if they cannot or will not participate in such trials.

Cancer control following anatomical radical prostatectomy: an interim report

Cancer control following anatomical radical prostatectomy was evaluated in 586 men who were followed for 1 1/2 to 8 years (median followup 4 years, 166 men followed 5 years or longer). The 5-year actuarial rate was 4% for local recurrence alone, 5% for distant metastases alone, 2% for distant metastases in association with local recurrence and 3% for death of or with disease, while 10% of the men had elevated levels of prostate specific antigen without local recurrence or distant metastases. When the actuarial status at 5 years was evaluated by clinical stage there was local recurrence alone in 0% of men with a clinical stage A1 or B1 nodule, and 4% with stage B1, 7% with stage A2 and 8% with stage B2 disease. When evaluated by pathological stage at 5 years local recurrence alone was noted in 2% of men with organ-confined disease, 8% with specimen-confined disease and 8% in whom the disease involved the surgical margin, seminal vesicles or pelvic lymph nodes. Recognizing that two-thirds to three-quarters of all local recurrences occur within the first 5 years, these data suggest that the anatomical approach to radical prostatectomy is associated with local control rates that are equal to or greater than other series reported in the literature. However, without a randomized study it is impossible to compare one clinical series to another, and followup evaluations at 10 and 15 years will be necessary to confirm these findings.

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

There is no consensus on the proper management of men with stage D1 adenocarcinoma of the prostate. Although cure is unlikely, many men survive for long intervals apparently free of metastatic disease. Thus, effective palliation of the local lesion with low morbidity is desirable. From 1974 to 1987, 120 consecutive men with stage D1 prostate cancer were treated with 3 primary modes of therapy (mean followup 48 months): 1) expectant therapy (35), 2) external beam radiotherapy (21) and 3) radical prostatectomy (64). These patients were statistically homogeneous as determined by Gleason grade but not by extent of metastatic disease. The over-all 5 and 10-year projected actuarial survival rates for the radical prostatectomy patients were 97 and 62%, respectively, and the apparent clinical survival free of disease at 5 years and 80 months, respectively, was 83 and 68%. The direct disease-specific 10-year survival free of disease was 46%. However, only 3 of 27 patients followed for 3 years or longer had undetectable levels of prostate specific antigen. Using a Cox univariate proportional hazards model several factors appeared to have significant prognostic value including volume of lymph node metastases (macroscopic greater than 2 mm.), percentage of positive lymph nodes sampled and frozen section diagnosis. Gleason grade, clinical stage and the number of positive nodes did not have significant prognostic value. Local recurrence requiring an operation was noted in 8 of 35 patients (23%) treated expectantly, 5 of 21 (24%) treated with radiotherapy and 2 of 64 (3%) treated with radical prostatectomy. Significant gastrointestinal or genitourinary complications occurred in 33% of the men treated with radiotherapy and 1.5% of those undergoing radical prostatectomy. Since the introduction of nerve-sparing radical prostatectomy in 1982, potency resumed in 55% of the 33 patients who were potent preoperatively and have been followed 1 year or longer. These data suggest that in properly selected patients radical prostatectomy, although not curative, can provide excellent palliation of the local lesion with acceptable morbidity and that symptomatic local recurrence of prostatic cancer achieved with radiation therapy is identical to the results in men who were managed expectantly.